Physical Therapist

Position Title: Clinical Reviewer - DMEPOS Prior Approval (Medicaid)

Position Summary: The Clinical Reviewer is responsible for evaluating Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) prior authorization requests for Medicaid members. This role utilizes clinical expertise, regulatory knowledge, and professional judgment to determine medical necessity, Medicaid coverage eligibility, and compliance with New York State regulations.

Key Responsibilities:

• Conduct comprehensive clinical reviews of DMEPOS prior authorization requests for Medicaid members to determine coverage eligibility under New York State Medicaid guidelines and regulations.
• Apply clinical knowledge and professional judgment to assess medical necessity and ensure requested equipment, supplies, or services appropriately meet members' healthcare needs.
• Review medical records, treatment plans, physician documentation, and supporting clinical information to support coverage determinations.
• Participate in the Fair Hearing process by preparing written clinical justifications and representing the Medicaid Prior Approval Department during telephonic hearings.
• Utilize knowledge of NYCRR Title 10 and Title 18 regulations, Medicaid policies, and national coding standards (CPT, HCPCS, ICD) to support accurate decision-making.
• Identify potential fraud, waste, and abuse through detailed review of requests and supporting documentation.
• Collaborate with physicians, healthcare providers, members, and external stakeholders through written and verbal communication.
• Maintain accurate documentation and ensure compliance with departmental quality standards and timelines.

Minimum Qualifications

• Current professional healthcare license/registration in New York State (RN preferred).
• Strong written and verbal communication skills.
• Experience reviewing medical records, treatment plans, and clinical documentation for medical necessity.
• Experience with prior authorization, utilization review, case management, clinical appeals, or DMEPOS reviews preferred.
• Experience evaluating and developing medical justification for durable medical equipment and related services.
• Proficiency in Microsoft Office Suite and standard business technologies.
• Ability to work independently and collaboratively in a team-oriented environment.
• Flexibility to work weekends or adjusted schedules when business needs require.